Ashline, Wesley NEW YORK STATE DEPARTMENT OF HEALTH b
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Wesley A. Ashline Male
Date o�ff DDe th Age If Veteran of U.S. Armed Forces,
04/301 008 45 years War or Dates
t Place of Death Hospital, Institution or
Z City, Town o gXXXX City Of Glens Falls Street Address Glens Falls Hospital
Ili0 Manner of Death Natural Cause 0 Accident Homicide 0 Suicide Undetermined Pending
Circumstances Investigation
tu Medical Certifier Name Title
1 Farhana Kama! M
Addrtians Falls Hospital 100 Park Street Glens Falls
Death Certificate Filed District Number Register Number
Ci , Town c I g XXXX City Of Glens Falls 5801 184
❑Burial Date Cemetery or Crematory
05/02l2008 Pine View Crematorium
Wictombment Address
Crematio Queensbury, NY 12804
Date Place Removed
Z❑Removal and/or Held
and/or Address
I= Hold
41)
0 Date Point of
Q Transportation Shipment
Es by Common Destination
Carrier
0 Disinterment Date Cemetery Address
0 Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Jillson Funeral Home, Inc. 00833
Addrslliams Street Whitehall, NY 12887
Name of Funeral Firm Making Disposition or to Whom
Iiiir, Remains are Shipped, If Other than Above
X Address
Cr
ill
': Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/02/2006 Registrar of Vital Statistics ` 7
g �5�i�.�"/7"L /L'v Lv
(signature)
District Number 5 bo) Place 6 6,,.,... - co, \ ` Sd r
;.:>.:: I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
k
ta Date of Disposition s-/2/0, Place of Disposition Pi 4441,ov Ccr w. t d r i
W (address)
to
Cr (section) (lot number) (grave number)
0
Ct Name of Sexton or Person in Charge of Premises a" S 'h,nt(A"
/� (please print)
1 Signature C. Title Crc'''r‘51:)f
(over)
DOH-1555 (02/2004)